Subscribe to RSS
DOI: 10.1055/s-2006-948320
Postresuscitative Intensive Care: Neuroprotective Strategies after Cardiac Arrest
Publication History
Publication Date:
10 August 2006 (online)

ABSTRACT
Cardiac arrest is a common disease in the United States, and many patients will die as a result of the neurological damage suffered during the anoxic period, or will live in a neurologically debilitated state. When cardiopulmonary-cerebral resuscitation results in the return of spontaneous circulation, intensive care is required to optimize neurological recovery. Such “brain-oriented” therapies include routine care, such as positioning and maintenance of volume status; optimization of cerebral perfusion, with the use of vasopressors if needed; management of increased intracranial pressure with agents such as hypertonic saline; assuring adequate oxygenation and avoiding hypercapnia; aggressive fever control; intensive glucose control, with the use of an insulin drip if needed; and management of seizures if they occur. To date, no neuroprotectant medications have been shown to improve neurological outcome. Induced moderate therapeutic hypothermia is utilized as a neuroprotective maneuver. Future treatment options and advanced monitoring techniques are also discussed. Further study to optimize neuroprotective strategies when treating patients who survive cardiac arrest is needed.
KEYWORDS
Postresuscitation - cardiopulmonary-cerebral resuscitation (CPCR) - cardiac arrest
REFERENCES
-
1 O'Neil B J, Krause G S, Grossman L I et al..
Global brain ischemia and reperfusion by cardiac arrest and resuscitation . In: Paradis N, Halpern H, Nowak R Cardiac Arrest: The Science and Practice of Resuscitation Medicine. Baltimore: Williams and Wilkins 1996: 84-112 - 2 Herlitz J, Andersson E, Bang A et al.. Experiences from treatment of out-of-hospital cardiac arrest during 17 years in Goteborg [see comments]. Eur Heart J. 2000; 21 1251-1258
- 3 Krause G S, Kumar K, White B C et al.. Ischemia, resuscitation, and reperfusion: mechanisms of tissue injury and prospects for protection. Am Heart J. 1986; 111 768-780
- 4 Pusswald G, Fertl E, Faltl M, Auff E. Neurological rehabilitation of severely disabled cardiac arrest survivors: Part II. Life situation of patients and families after treatment. Resuscitation. 2000; 47 241-248
- 5 Advances in cardiovascular life support-section 8: postresuscitation care. Circulation. 2000; 102(suppl I) I166-I177
- 6 Safar P. On the history of modern resuscitation. Crit Care Med. 1996; 24(suppl) S3-S11
- 7 Bell D D, Brindley P G, Forrest D, Al Muslin O, Zygun D. Management following resuscitation from cardiac arrest: recommendations from the 2003 Rocky Mountain Critical Care Conference. Can J Anaesth. 2005; 52 309-322
- 8 Sundgreen C, Larsen F S, Herzog T M et al.. Autoregulation of cerebral blood flow in patients resuscitated from cardiac arrest. Stroke. 2001; 32 128-132
- 9 Mullner M, Sterz F, Binder M et al.. Arterial blood pressure after human cardiac arrest and neurological recovery. Stroke. 1996; 27 59-62
- 10 Sterz F, Leonov Y, Safar P et al.. Hypertension with or without hemodilution after cardiac arrest in dogs. Stroke. 1990; 21 1178-1184
- 11 Bhardwaj A, Ulatowski J. Hypertonic saline solutions in brain injury. Curr Opin Crit Care. 2004; 10 126-131
- 12 Sakabe T, Tateishi A, Miyauchi Y et al.. Intracranial pressure following cardiopulmonary resuscitation. Intensive Care Med. 1987; 13 256-259
-
13 Bhardwaj A.
Cerebral edema and intracranial hypertension . In: Bhardwaj A, Mirski MA, Ulatowski JA Handbook of Neurocritical Care. Totowa, NJ; Humana Press 2004 -
14 Ropper A H, Rockoff M A.
Physiological and clinical aspects of raised intracranial pressure . In: Ropper AH Neurological and Neurosurgical Intensive Care. 3rd ed. New York; Raven Press 1993: 11-28 - 15 Ausina A, Baguena M, Nadal M et al.. Cerebral hemodynamic changes during sustained hypocapnia in severe head injury: can hyperventilation cause cerebral ischemia?. Acta Neurochir Suppl. 1998; 71 1-4
- 16 Diringer M N, Yundt K, Videen T O et al.. No reduction in cerebral metabolism as a result of early moderate hyperventilation following severe traumatic brain injury. J Neurosurg. 2000; 92 7-13
- 17 Yundt K D, Diringer M N. The use of hyperventilation and its impact on cerebral ischemia in the treatment of traumatic brain injury. Crit Care Clin. 1997; 13 163-184
- 18 Grubb N R. Managing out-of-hospital cardiac arrest survivors: 1. Neurological perspective. Heart. 2001; 85 6-8
- 19 Zeiner A, Holzer M, Sterz F et al.. Hyperthermia after cardiac arrest is associated with an unfavorable neurologic outcome. Arch Intern Med. 2001; 161 2007-2012
- 20 Eisenburger P, Sterz F, Holzer M et al.. Therapeutic hypothermia after cardiac arrest. Curr Opin Crit Care. 2001; 7 184-188
- 21 Sieber F E, Traystman R J. Special issues: glucose and the brain. Crit Care Med. 1992; 20 104-114
- 22 Parsons M W, Barber P A, Desmond P M et al.. Acute hyperglycemia adversely affects stroke outcome: a magnetic resonance imaging and spectroscopy study. Ann Neurol. 2002; 52 20-28
- 23 Weir C J, Murray G D, Dyker A G, Lees K R. Is hyperglycemia an independent predictor of poor outcome after acute stroke? Results of a long-term follow-up study. BMJ. 1997; 314 1303-1306
- 24 Williams L S, Rotich J, Qi R et al.. Effects of admission hyperglycemia on mortality and costs in acute ischemic stroke. Neurology. 2002; 59 67-71
- 25 Woo E, Chan Y W, Yu Y L, Huang C Y. Admission glucose level in relation to mortality and morbidity outcome in 252 stroke patients. Stroke. 1988; 19 185-191
- 26 Longstreth W T, Inui T S, Cobb L A, Compass M K. Neurologic recovery after out-of-hospital cardiac arrest. Ann Intern Med. 1983; 98 588-592
- 27 Longstreth Jr W T, Copass M K, Dennis L K et al.. Intravenous glucose after out-of-hospital cardiopulmonary arrest: a community-based randomized trial. Neurology. 1993; 43 2534-2541
- 28 Van den Berghe G, Wouters P, Weekers F et al.. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001; 345 1359-1367
-
29 Longstreth W T.
Neurologic complications of cardiac arrest . In: Aminoff MJ Neurology and General Medicine. 3rd ed. Philadelphia; Churchill Livingstone 2001: 151-170 - 30 Celesia G G, Grigg M M, Ross E. Generalized status myoclonus in acute anoxic and toxic-metabolic encephalopathies. Arch Neurol. 1988; 45 781-784
- 31 Krumholz A, Stern B J, Weiss H D. Outcome from coma after CPR: relation to seizures and myoclonus. Neurology. 1988; 38 401-405
- 32 Arnoldus E PJ, Lammers G J. Postanoxic coma: good recovery despite myoclonic status. Ann Neurol. 1995; 38 697-698
- 33 Wijdicks E FM, Parisi J E, Sharbrough F W. Prognostic value of myoclonus status in comatose survivors of cardiac arrest. Ann Neurol. 1994; 35 239-243
- 34 Buunk G, van der Hoeven J G, Meinders A E. Cerebral blood flow after cardiac arrest. Neth J Med. 2000; 57 106-112
- 35 Werhahn K J, Brown P, Thompson P D, Marsden C D. The clinical features and prognosis of chronic posthypoxic myoclonus. Mov Disord. 1997; 12 216-220
- 36 Krumholz A, Berg A. Further evidence that for status epilepticus “one size fits all” doesn't fit. Neurology. 2002; 58 515-516
- 37 Jörgensen E O, Holm S. Prediction of neurological outcome after cardiopulmonary resuscitation. Resuscitation. 1999; 41 145-152
- 38 Goh W C, Heath P D, Ellis S J, Oakley P A. Neurologic outcome prediction in a cardiorespiratory arrest survivor. Br J Anaesth. 2002; 88 719-722
- 39 Young G B, Gilbert J J, Zochodne D W. The significance of myoclonic status epilepticus in postanoxic coma. Neurology. 1990; 40 1843-1848
- 40 Bernard S A, Gray T W, Buist M D et al.. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002; 346 557-563
- 41 Longstreth W T, Fahrenbruch C E, Olsufka M et al.. Randomized clinical trial of magnesium, diazepam, or both after out-of-hospital cardiac arrest. Neurology. 2002; 59 506-514
- 42 Lindner K H, Dirks B, Strohmenger H U et al.. Randomised comparison of epinephrine and vasopressin in patients with out-of-hospital ventricular fibrillation. Lancet. 1997; 349 535-537
- 43 Gueugniaud P Y, Mols P, Goldstein P et al.. A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. European Epinephrine Study Group. N Engl J Med. 1998; 339 1595-1601
- 44 Stiell I G, Hebert P C, Wells G A et al.. Vasopressin versus epinephrine for inhospital cardiac arrest: a randomized controlled trial. Lancet. 2001; 358 105-109
- 45 A randomized clinical trial of calcium entry blocker administration to comatose survivors of cardiac arrest: design, methods, and patient characteristics. The Brain Resuscitation Clinical Trial II Study Group. Control Clin Trials. 1991; 12 525-545
- 46 Jastremski M, Sutton-Tyrrell K, Vaagenes P et al.. Glucocorticoid treatment does not improve neurological recovery following cardiac arrest. Brain Resuscitation Clinical Trial I Study Group. JAMA. 1989; 262 3427-3430
- 47 Safar P. On the history of modern resuscitation. Crit Care Med. 1996; 24(suppl) S3-S11
- 48 Bottiger B W, Martin E. Thrombolytic therapy during cardiopulmonary resuscitation and the role of coagulation activation after cardiac arrest. Curr Opin Crit Care. 2001; 7 176-183
- 49 Koehler R C, Michael J R. Cardiopulmonary resuscitation, brain blood flow and neurologic recovery. Crit Care Clin. 1985; 1 205-222
- 50 Cohan S L, Mun S K, Petite J. Cerebral blood flow in humans following resuscitation from cardiac arrest. Stroke. 1989; 20 761-765
- 51 Lee S K, Vaagenes P, Safar P. Effect of cardiac arrest time on cortical cerebral blood flow during subsequent standard external cardiopulmonary resuscitation in rabbits. Resuscitation. 1989; 17 105-117
- 52 Safar P. Cerebral resuscitation after cardiac arrest: research initiatives and future directions. Ann Emerg Med. 1993; 22 324-349
- 53 Sterz F, Leonov Y, Safar P et al.. Multifocal cerebral blood flow by Xe-CT and global cerebral metabolism after prolonged cardiac arrest in dogs: reperfusion with open-chest CPR or cardiopulmonary bypass. Resuscitation. 1992; 24 27-47
- 54 Schreiber W, Gabriel D, Sterz F et al.. Thrombolytic therapy after cardiac arrest and its effect on neurological outcome. Resuscitation. 2002; 52 63-69
- 55 Hekmatpanah J. Cerebral blood flow dynamics in hypotension and cardiac arrest. Neurology. 1973; 23 174-180
- 56 Bottiger B W, Motsch J, Bohrer H et al.. Activation of blood coagulation after cardiac arrest is not balanced adequately by activation of endogenous fibrinolysis. Circulation. 1995; 92 2572-2578
- 57 Van Campen L CMC, van Leeuwen G R, Verheugt F WA. Safety and efficacy of thrombolysis for acute myocardial infarction in patients with prolonged out-of-hospital cardiopulmonary resuscitation. Am J Cardiol. 1994; 73 953-955
- 58 Gore J M, Sloan M, Price T R et al.. Intracerebral hemorrhage, cerebral infarction and subdural hematoma after acute myocardial infarction and thrombolytic therapy in the Thrombolysis in Myocardial Infarction Study. Circulation. 1991; 83 448-459
- 59 Scholz K H, Tebbe U, Herrmann C et al.. Frequency of complications of cardiopulmonary resuscitation after thrombolysis during acute myocardial infarction. Am J Cardiol. 1992; 69 724-728
- 60 Bottiger B W, Bode C, Kern S et al.. Efficacy and safety of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation: a prospective clinical trial. Lancet. 2001; 357 1583-1585
- 61 Kariman K, Hempel F G, Jobsis F F. In vivo comparison of cytochrome a/a3 redox states and tissue pO2 in transient anoxia. J Appl Physiol. 1983; 55 1057-1063
- 62 Kiening K L, Unterberg A W, Bardt T F et al.. Monitoring of cerebral oxygenation in patients with severe head injuries: brain tissue pO2 versus jugular vein oxygen saturation. J Neurosurg. 1996; 85 751-757
- 63 Dings J, Meixensberger J, Amschler J, Hamelbeck B, Roosen K. Brain tissue pO2 in relation to cerebral perfusion pressure, TCD findings and TCD-CO2 reactivity after severe head injury. Acta Neurochir (Wien). 1996; 138 425-434
- 64 Gopinath S P, Valadka A B, Uzura M et al.. Comparison of jugular venous oxygen saturation and brain tissue pO2 as monitors of cerebral ischemia. Crit Care Med. 1999; 27 2337-2345
- 65 Goodman J C, Valadka A B, Gopinath S P, Uzura M, Robertson C S. Extracellular lactate and glucose alterations in the brain after head injury measured by microdialysis. Crit Care Med. 1999; 27 1965-1973
- 66 Lewis K S, Kane-Gill S L, Bobek M B, Dasta J F. Intensive insulin therapy for critically ill patients. Ann Pharmacother. 2004; 38 1243-1251
Wendy L WrightM.D.
Assistant Professor, Neuroscience Critical Care and Cerebrovascular Disease, Departments of Neurology and Neurosurgery, Emory University Hospital
1365B Clifton Road, NE, Suite 2200, Atlanta, GA 30322